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Waterpipe Tobacco Smoking Briefing: 13 Waterpipe tobacco smoking © 2013 National Centre for Smoking Cessation and Training (NCSCT) Authors: Mohammed Jawad, Andy McEwen, Ann McNeill & Lion Shahab Editors: Andrew Preston, Melanie McIlvar, Andy McEwen This briefing is based upon an article in the journal Addiction1 and has been prepared by the NCSCT to provide stop smoking practitioners with a summary of the evidence and guidance on the information they can give to their clients. Executive summary ■ Waterpipe tobacco smoking is increasing and the UK has reported a 210% rise in the number of waterpipe cafes nationwide over the last five years. ■ Despite a widespread belief amongst waterpipe tobacco smokers that it is a low risk activity, waterpipe tobacco smoke is known to contain significant levels of toxins including some which are known to be carcinogenic (i.e. causes cancer). ■ There is evidence of significant negative health effects from waterpipe tobacco smoking. ■ Waterpipe tobacco smoking therefore represents both an individual health issue for clients attending stop smoking services, and a potential public health concern. www.ncsct.co.uk 1 Briefing: 13 Waterpipe tobacco smoking Waterpipe smoking: history and practice Waterpipe smoking is a broad term given to a device whereby smoke (usually sourced from a tobacco mixture) is passed through water prior to inhalation.2 Figure 1: Example of a waterpipe with schematic1 Coal Foil Head Tobacco Smoke flow Hose Body Mouthpiece Water Bowl Smokeflow The origins of waterpipe tobacco smoking are thought to date back several centuries, although its exact beginning is uncertain.3 There are a variety of cultural and regional variations in its use, thus it is synonymously known across the world by other terms such as hookah, shisha, narghile, goza or hubble bubble.3 This range of cultural names is partly reflective of the different types of tobacco used. The most commonly used waterpipe tobacco is called the Mo’assel which means ‘honeyed’ and is made up of about one-third tobacco mixed with two-thirds honey and fruit flavours.4 It is separated from heated coal in the waterpipe by pierced aluminium foil. There are also unflavoured waterpipe tobacco forms known as Ajami, Tumbak, or Jurak, which may have a higher tobacco ratio, and be in direct contact with the heated coal4 in waterpipes. www.ncsct.co.uk 2 Briefing: 13 Waterpipe tobacco smoking The Chinese variant of waterpipe contains very little tobacco, and no coal.5 More recently the waterpipe industry has marketed two new variants: firstly, a non-tobacco, herbal variant, claiming to provide a healthier alternative to the Mo’assel tobacco6, and secondly electronic waterpipe devices attempting to emulate e-cigarettes.7 Understanding these differences is important when critiquing the available evidence on the health effects of waterpipe use, as each type of tobacco mixture has a different smoke composition of varying concentrations with slightly different health effects.8 Most of the recent literature generally refers to the fruit-flavoured Mo’assel type, and it is this type of waterpipe that is discussed in this briefing, unless stated otherwise. Unlike cigarettes, a waterpipe is commonly smoked intermittently and in groups.9–12 It provides a central activity at social gatherings, and is usually smoked for 45–60 minutes13, but sometimes longer.14 The United Kingdom has reported a 210% rise in the number of waterpipe cafes nationwide over the last five years;15 a regular location for smokers. However, smoking is also commonplace in the home11,12,16,17 as this is considered cheaper and less time consuming.18 Waterpipe tobacco use can be associated with other forms of substance abuse, most commonly cigarettes but also recreational drugs,9,19,20–23 with reports that narcotics and alcohol can be mixed with the waterpipe tobacco and water respectively to add to its psychoactive effect.18,24 Prevalence and epidemiology Currently good epidemiological trend data on waterpipe smoking is lacking, in part due to the absence of its inclusion in national health surveys.25 The full picture is further complicated by the fact that waterpipe users do not generally self-identify as smokers26 resulting in a tobacco-using population that healthcare professionals are not able to routinely identify.27 Whilst males are more likely to smoke waterpipes than females,28 this gender difference is smaller than that seen for cigarette use, especially in countries where there is a usual gender divide in cigarette use.29 There is no clear trend on socio-economic status predicting waterpipe use, but it may be more prevalent among the more educated and affluent.30–32 Recent longitudinal data suggests an upwards trend which persist across all age groups, but is particularly noticeable in the younger population. In the UK the current prevalence is thought to be 8% amongst school pupils33 and 8–19% amongst university students.25,34,35 www.ncsct.co.uk 3 Briefing: 13 Waterpipe tobacco smoking Health consequences of waterpipe tobacco smoking Controlling for the extensive habitual variables of waterpipe smoking such as breathing patterns, size of the waterpipe,36 and materials used,37 has proven difficult when conducting smoke aerosol studies using machine-replicated human behaviour models.38 However, there has been consistency in the production of significant noxious chemicals including tar, carbon monoxide, nitric oxide and various carcinogens. Attempts have been made to compare these toxicant yields to the amount produced by a single cigarette. Interestingly, despite being marketed as a healthier alternative, it is shown that herbal variants of waterpipe contain significant levels of toxicants, except for nicotine, similar to normal waterpipe Mo’assel. Additionally, one study has shown that waterpipe tobacco delivers substantial amounts of heavy metals including arsenic, beryllium and chromium graded 1 (which is carcinogenic) by the International Agency for Research on Cancer.39 Waterpipe tobacco is known to contain and deliver other carcinogens, e.g. concentrations of radionuclide elements such as uranium, and polonium 40,41 and tobacco-specific nitrosamines, but in lower amounts than seen in cigarette smokers.42 A key health concern, in the acute setting at least, is the threat of CO poisoning 43–50 where smokers generally experience non-specific neurological signs such as light headedness and nausea.11 Waterpipe smokers usually recall a ‘buzz’ when smoking, which may reflect the early stages of CO poisoning.51 The carbon monoxide in waterpipe tobacco smoke results from the combustion of coal, which is why CO levels are high, even when replacing the tobacco with herbal variants. In addition, the burning of coals or ‘natural coals’ (such as those made from coconuts) also produces significant levels of carcinogenic polycyclic aromatic hydrocarbons (PAHs).52 Chronic exposure to CO may have implications in maintaining blood oxygenation, a concern for surgeons and anaesthetists,53 and is a risk factor in itself for cardiovascular disease. A final potential health threat, created from the sharing of waterpipes in close proximity between users, is the possibility of infection transmission, in particular tuberculosis,54 but other organisms have been shown to exist inside the waterpipe apparatus.55 www.ncsct.co.uk 4 Briefing: 13 Waterpipe tobacco smoking A review of the literature concluded that waterpipe smoking can result in levels of up to ten cigarettes’ worth of nicotine among daily waterpipe smokers.56 Although studies on the health effects of waterpipe tobacco smoking tend to be lacking or of low quality, various detrimental health effects from waterpipe smoking have been established. A recent systematic review could not rule out associations with: ■ bladder cancer; ■ nasopharyngeal cancer (cancer of the upper throat); ■ oesophageal (gullet) cancer; or ■ infertility 57 High carcinoembryonic antigen levels (CEA) levels, implicated in the spread of cancers, have also been documented amongst waterpipe smokers.58 Further evidence shows similar effects of waterpipe tobacco smoking and cigarette smoking on lung function59,60 and waterpipe tobacco smoking has also been implicated in the development of chronic obstructive pulmonary disease (COPD).61 Although there is relatively little evidence in the way of long-term health effects on the heart, acute effects of waterpipe tobacco smoking include increases in heart rate and systolic / diastolic blood pressure62–64 as well as impaired baroreflex (the mechanism for regulating blood pressure) sensitivity.65 Moreover, ‘herbal’ waterpipe use can also contribute to such impairment of pulse and blood pressure.66 www.ncsct.co.uk 5 Briefing: 13 Waterpipe tobacco smoking Dependence and cessation As waterpipes can deliver levels of nicotine similar to cigarettes, levels which are considered to lie above the ‘addiction threshold’,67 we can conclude that waterpipe tobacco smoking has the potential to induce dependence.56 However, the pattern of dependence is likely to be different from that of cigarettes. It is likely to be shaped by the different mechanisms of delivering nicotine, social context,12,68 and sensory cues (aromatic smell, flavoured taste, decorative sight, bubbling sound), as well as different individual smoking behaviour and waterpipe tobacco brand preference69 to that of cigarettes. Furthermore, waterpipe tobacco smoking has been shown to suppress recognised nicotine withdrawal symptoms and cravings in smokers, and so has the ability to undermine
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